Aug 18, 2014

Population Health Needs A Brand Positioning Strategy

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Population Health (PH) is a term that has become ingrained in the Healthcare Reform lexicon over the past decade. It’s one of those politically gravitational conveniences that allow candidates from different parties to embrace a common goal with little risk of being criticized for holding beliefs different than their opponent. And that is precisely because it is difficult, if not impossible, to prove someone believes in something that does not have a consistent and agreed upon definition.

Just What is Population Health?
What PH enjoys in broad political support it lacks in definitional credibility. A good treatise on variations of contemporary definitions can be found in Academy Health’s Population Health in the Affordable Care Act Era by Michael Stoto, Ph.D. Without wanting to deliberately adulterate that work, Stoto highlights conceptual commonalities and differences in definitions from several sources that I will try and very briefly summarize below.

A focus on health outcomes – the subjectivity of which notwithstanding – and the distribution of outcomes (i.e., how do outcomes vary across comparative stratifications, such as geographic residence, ethnicity, age, etc.)

The impetus of achieving healthier outcomes is through encouraging healthier lifestyles, better nutrition, preventative care, avoiding behavioral risks, etc.

Measurement of health status indicators as well as the factors that are correlated with those indicators (e.g., socioeconomic conditions, physical environments, childhood development, etc.)

Utilization of data and analytics to develop a conceptual framework for understanding and explaining differences in population health indicators – and how that knowledge impacts research agendas, resource allocations and public policy.

Often discussed (or confused, depends on your perspective) with public health, though the latter also typically connotes a governmental influence of some type (e.g., a municipal health department).

Policy Perspectives
From a policy perspective, there are two ways to look at PH: altruistic and pragmatic. From an altruistic perspective policies that promise to improve population health are most often framed in cost—benefit analyses: the benefits, if achievable, are easy to agree upon (who doesn’t want to be healthier?). The ROI is the challenge and most often the subject of political contention.

From a pragmatic perspective – particularly as PH has been manifested in the Affordable Care Act – what we are really talking about is cost control. Healthier people demand less healthcare services. Individuals with chronic conditions that more effectively manage those conditions need less healthcare. Economics 101: if we can reduce demand while maintaining or increasing supply, costs should decrease.

Parallel to this latter perspective is the growing base of knowledge that indicates improving the quality of care can achieve both lower costs AND better care. So if population health is a vehicle through which quality can be improved, it benefits from that additional policy advocacy.

Population Health Perceptions
Population Health means different things to different people. A good part of that difference can be explained in the inherent subjectivity of the concept of health outcomes. Some other portion can be explained by academic exercises seeking to cut the Gordian Knot. Still another by political extrapolations that seek to gain favor by equating improved population health with an appreciative electorate.

Whatever the feasible explanation(s) may be, Population Health suffers from an identity crisis. Beyond just a definitional problem, however, it fundamentally lacks in having been able to achieve a shared understanding of its meaning and purpose at a level that resonates with the very “population” whose health is of concern. In short, PH could use a brand positioning strategy.

Perceptual Positioning of Population Health
One of my favorite books on branding is Brand: It Ain’t the Logo: It’s what people think of  you™ by Ted Matthews. Matthews argues that,

“a brand is the sum total impression and memory of every remarkable, every so-so and every negative experience with any and all pieces of an organization. A brand is the personality of [that organization] . . . and is judged and assessed a value by everyone it touches, whether inside the [organization] or outside. These perceptions of value may, or may not, be what you want them to be. Which suggests a fact that may surprise you: your brand isn’t really yours (emphasis added). You don’t own it – all the people thinking about you do.”

It’s not a leap to borrow or migrate these concepts of perceptual brand positioning to PH. Many proponents of PH take an interventional approach as a means to advocacy. Their focus is on modifying individual behaviors, inducing health screening, creating artificial employment incentives and imposing restrictions and/or impositions on environmental elements. This is not a sustainable approach to PH brand positioning simply because it fails to recognize that the perception of PH is owned by the individual – and not the advocate.

What to do Differently
When I was giving presentations across the country a few years back on the newly passed Affordable Care Act, I made it a point to say that I believed if we were somehow successful in increasing access to healthcare services, in improving quality, in lowering costs, in enhancing efficiency and productivity – that none of that would matter long-term because the forecasted demand from an aging demographic would atomize those gains.  The only escape from a tragic gap between demand for quality healthcare and the ability to meet that demand will come from lowering innate demand.

Population health, however one wants to define it, is therefore a critical component of any strategy that seeks to address the looming care gap. But the underlying concepts of what make improving population health mutually beneficial cannot be thrust upon individuals for their own good. Nobody ever bought a Macintosh computer because Steve Jobs told them they should. If you are an advocate of PH, then it’s time to start looking at how to perceptually position its brand benefits differently.

Look at the most valuable brands in the world, and look at how they were built: such as Apple, Microsoft, Coca-Cola, IBM, Google, Disney. Marketing and advertising played important roles, but it has ultimately been each organization’s ability to offer something of value to individuals that drove sustainable perceptions. What can be learned from the branding strategies of organizations like these that can turn the perceptual positioning of Population Health on its head to achieve the long-term benefits that we believe can be achieved?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Population Health · Tagged: , , , , , ,
Aug 13, 2014

Depression, Addiction & Mental Health Policy

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Pic For BlogThe last time I remember feeling as badly about a celebrity passing has to be December 8, 1980. I remember exactly where I was and what I was doing when a radio disk jockey (people that used to play and broadcast what were known as records on electronic turntables) broke the news over a song that John Lennon had been shot. About two minutes later, the music was stopped – and the sad news announced that he had been shot – and killed.

Queue up round the clock Beatles music and millions of tears across the world.  The next day in the Rock n Roll capital was damp and dreary. A cold mist just seemed to hang in the air. One of those days where ironically it would feel warmer if it would have just snowed. There are a lot of days like that in early December in Cleveland, Ohio. But this one so fit the mood.

Nobody saw that one coming. Whereas we all know now what only a few knew all to well before Monday: that Robin Willams’ mental demons were probably always only a few steps behind. Shadowing him like the inescapable darkness of a night in the forest, depression is a disease that lurks, pounces, retreats and then stalks – taking in turn at random how it chooses to haunt its victims.

Addiction, on the other hand, despite the cultural shift in attitudes over the past few decades, is not a disease. Writing in the Psychology Today blog a couple of years back, Dr. Lance Dodes explains how addiction has little in common with other diseases and cannot be explained by any disease process. But as he also astutely points out, neither is it the purview of individuals lacking in discipline and morality,  just being selfish and self-centered.

But to understand addiction is to understand the mental state of an individual leading up to and perpetuating its hold on that person.  Dr. Lance writes, “addictive behavior is a readily understandable symptom, not a disease.” In Williams’ case the connection between depression and resulting behavior leading to addiction is something that should continue to build awareness and understanding.

I realize it’s a sensitive line here because the last thing we want to do is roll back the progress made fighting stigmatization and the barrier and obstacles that has created in affecting treatment access. On the other hand, from a public policy perspective it is crucial that we continue to dig deeper: to understand mental health – and mental illness – as a critically holistic element impacting all varieties of personal well being, not just as a precept to alcoholism and addiction.

Robin Williams’ wife has asked that we remember her husband by not focusing on his death, “but on the countless moments of joy and laughter he gave to millions.” As the emotional pain subsides I am certain we will be able to do that. Before we get to that place, however, it is natural to question and seek answers on how this tragedy might have been avoided.

For millions of Americans suffering from, or affected by a loved one suffering from, a mental illness, alcoholism or addiction, Robin Williams’ death is a painful reminder of the fear and vulnerability they live with every day. And they are right to be questioning what might be done to help address that suffering. Yesterday, Rep. Tim Murphy (R-Pa) noted that, “Williams’ greatest gift to us, if we choose to accept it, is a focused determination to help those with brain illness and finally take real action to stop the loss of one more precious life.”

In December of last year, in response to the 2012 elementary school shooting in Connecticut, Murphy – a clinical psychologist – introduced H.R. 3717, The Helping Families in Mental Health Crisis Act. One of the most important initiatives in the bill is to address the Institutions for Mental Disease (IMD) Exclusion, which limits Medicaid coverage for inpatient mental health and addiction treatment.

The bill is complex, comprehensive and has faced a significant amount of criticism. Good coverage of this can be found in a blog post from Gary Earles, LICSW, writing last year for the Morning Zen on the Children’s Mental Health Network. Very doubtful that even with this latest tragedy the bill will move anywhere before the next Congress is installed. But what might now happen is the debate will move from the purview of policy wonks, trade groups and special interests into the real world where those aforementioned suffering can have a voice. We can only hope.

Cheers,
  Sparky

Filed Under: Depression & Addiction, Editorials & Opinions · Tagged: , , , , , , ,
Jul 22, 2014

As the ACA Turns

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So now what?

If the Affordable Care Act was a soap opera – and who’s to say it’s not – I think even Susan Lucci would have lost faith by now in the merits of a plot leading to any type of long-term resolution, clarity or certainty.

The U. S. Court of Appeals for the D.C. Circuit ruled today in the Halbig v. Burwell decision that the IRS had incorrectly allowed the subsidization of insurance premiums to millions of Americans covered under the Act’s health insurance exchanges. Then about an hour later, the U.S. Court of Appeals for the Fourth Circuit, in Richmond, argued that the IRS was within their legal power because the subsidies they provided were, “a permissible exercise of the agency’s discretion.”

Following along?

The Act provides that subsidies be provided to “state-run” exchanges, but whether through political objection or inability, 27 states opted to have the federal government establish and operate their exchanges while another 9 states opted to have their exchanges jointly ran by state and federal agencies. So by an interpretation of the letter of the law subsidies are unavailable to individuals living in those 36 states.

In writing the 2-to-1 majority opinion on the Halbig decision, Judge Thomas Griffith noted that, “we reach this conclusion, frankly, with reluctance.” Why? Because according to the Robert Wood Johnson Foundation an estimated 7.3 million people — about 62 percent of those expected to enroll in federal-run exchanges by 2016 — could lose out on $36.1 billion in insurance subsidies. Over 7 million individuals could be losing an average of $4,400 in annual subsidies (based on Congressional Budget Office estimates for the current year).

What each court had to wrestle with was whether it was Congress’ intent to provide expanded access to healthcare insurance through premium subsidization irrespective of whether the exchanges are ran by state or federal governments. Judge Griffith wrote that, “the fact is that the legislative record provides little indication one way or the other of congressional intent, but the statutory text does. Section 36B plainly makes subsidies available only on Exchanges established by states.”

And there’s the rub. Looking back to the summer of 2010, the legislative process leading to passage of the Affordable Care Act was ridiculously chaotic, incredibly politically charged and fraught with misinformation being spewed in all directions by nearly every stakeholder who could find a media outlet. All (as in both) parties being equally complicit in disinformation

John Earnest, White House press secretary noted, “you don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health care costs, regardless of whether it was state officials or federal officials who were running the marketplace. I think that is a pretty clear intent of the congressional law.”

I think he is wrong. It’s not clear because the legislative process leading up to and through passage was anything but. In fact, it can be effectively argued that lack of clarity was a direct result of favoring political expediency over legislative pragmatism. The Act is very poorly written and is fraught with these types of examples where implementation wasn’t very well thought through. But that lack of clarity – and legislative ambiguity in particular – is not grounds for overturning legislative intent.

Writing today in The New Republic, Brian Beutler argues that applying Supreme Court Justice Antonin Scalia’s concept of “overall statutory scheme,” that, “the words of a statute must be read in their context,” it is unambiguous that it was Congress’ intention through the ACA to provide insurance subsidies a priori of the means and mechanisms of the exchanges. Even if the argument could be made that it was ambiguous, Beutler notes that there is still the need to determine whether the law has been interpreted plausibly. In either case, it seems unlikely this latest attempt to derail the ACA will ultimately succeed.

But let’s assume that it does. I think it could easily be a case of be careful what you wish for because you might just get it for republicans. By the time this issue would make it through the Supreme Court there will be at least over 7 million individuals that are going to be told they will suddenly lose what then could reasonably be a $5,000 a year benefit. All that would be required to maintain the benefit would be an administrative language modification, which republicans could refuse as a plausible effort to cripple the Affordable Care Act. They would be in a politically very difficult spot – but then that seems to be a self-inflicted level of comfort they’ve grown accustomed to.

So stay tuned, as they say . . .

Cheers,
  Sparky

Picture credit: Time Magazine

Filed Under: Affordable Care Act, Editorials & Opinions · Tagged: , , , ,
Jul 16, 2014

The Lunacy of Our Mental Health Policy

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MEDICAID1-master675An institution for mental diseases (or, “IMD”) is defined as, “a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis, treatment, or care of persons with mental illness, including medical attention, nursing care, and related services” (42 U.S.C. §1396d(i)).

Last week the New York Times ran an article addressing the infamous Medicaid IMD exclusion: the culmination of state and federal policies dating back to the 19th century up to and including the Medicare Catastrophic Act of 1988, in which an IMD was infamously defined as a facility with more than 16 beds.

The apparent intent at that time was to promote small, community-based group living arrangements as an alternative to large institutions. But what has resulted is that Medicaid covers mental health treatment for a large percentage of people with Medicaid, but that coverage is excluded for inpatient treatment of adults aged 21 to 64 in any acute or long-term care institutions with 17 or more beds that are primarily engaged in providing treatment for mental illnesses. This is what is known as the Medicaid IMD exclusion.

Another indirect consequential reality of the IMD exclusion is what’s known as psychiatric boarding. The 1986 Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals participating in the Medicare program to provide a medical screening examination of any person presenting to its emergency department regardless of the ability to pay.  For psychiatric emergencies, an individual expressing suicidal or homicidal thoughts or gestures, if determined to be dangerous to themselves or others, the hospital must either provide treatment until their condition is stabilized – or transfer that person to an inpatient facility where the person can be treated until the condition is stabilized.

But there’s the rub: since so many individuals with mental illness (and addiction is considered a mental illness) are Medicaid patients there are very often limited alternatives for transfer.  Thus those patients tend to stay in emergency departments longer than necessary – an expensive consequence because of the cost intensive nature of ED’s. Communities work hard to develop informal diversion relationships to try and address the issues and challenges this creates: but their time could be better spent – like on improving patient care.

Section 2707 of the Affordable Care Act, Medicaid Emergency Psychiatric Demonstration, is a three-year pilot program that permits non-government psychiatric hospitals with more than 16 beds to receive Medicaid payment for providing EMTALA-related emergency services to Medicaid recipients aged 21 to 64 who have expressed suicidal or homicidal thoughts or gestures, and who are determined to be dangerous to themselves or others.

But this only addresses specifically-defined crises and will take a long time to be tested, evaluated and debated. It does not address the epidemical crisis we face as a nation with heroin addiction. So even though 26 states have willingly or unwillingly embraced Medicaid expansion under the ACA, many of the individuals needing inpatient treatment for addiction will be unable to receive that treatment.

A recent study published by researchers at the Boston Medical Center in the JAMA Internal Medicine Journal  reaffirmed the importance of combining inpatient and outpatient treat of heroin addiction. From the NYT article: for many suffering with heroin addiction, “there is an undeniable and essential need for residential treatment,” said Allen Sandusky, the South Suburban Council’s chief executive in Chicago.

Study after study has demonstrated that substance abuse treatment and rehabilitation is less expensive than incarceration as an alternative to addressing individual addiction and alcoholism. At the same time, economies of scale driving greater efficiency and lower program costs in facilities that allocate overhead over a larger number of beds is just economically intuitive.

When all these considerations are taken together with the skyrocketing costs associated with increasing crime and the burden being placed on community first responders as a direct result of the heroin epidemic it would seem like the biggest no-brainer in the history of earth is to legislatively repeal the IMD exclusion. Thus be to the ignominious wasteland that is Washington, DC.

At a time when communities across the country are scrambling to address a heroin epidemic that is literally destroying those communities and the families living there Congress is focused on a lawsuit against the president (the House) and an irrationally urgent need to reverse the Supreme Court’s innocuous Hobby Lobby decision (Senate). Shameful, truly shameful. Even more so than usual.

Cheers,
  Sparky

Photo credit: Armando L. Sanchez for The New York Times

Filed Under: Editorials & Opinions · Tagged: , , , , , , ,
Jun 28, 2014

Changing Our Perspective on Mental Health

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On Thursday I shared the post, Don’t Make Mental Health Policy About Stigma. Jessica Dawson, the brave woman who was one of several individuals featured in the USA Today article I reacted to in my post commented that she was, “discontented [her] photo is being used on [my blog] to discredit the impact which stigma has on government policies.”

I took that personally pretty hard as I had a sense I was betraying someone because of my ignorance on a subject that I am very passionate about and for which I have advocated here in the Pub. But I have to stick with what I wrote: not because I am sure I’m right – but because it’s what I wrote. In my response to Ms. Dawson I noted that I didn’t believe we had different goals but rather different beliefs in how to most effectively achieve those goals.

And then this morning I came across an article from earlier this week by Judith Solomon for the Center on Budget and Policy Priorities that is thematically consistent for what I was advocating: the pragmatic role that research and evidentiary support should play in advancing policies supportive of mental and behavioral health access and affordability – relative to (i.e., not exclusive of) the role fighting stigmatism can play in our current economic and political environment.

The article, The Truth About Health Reform’s Medicaid Expansion and People Leaving Jail, presents evidence that facilitating Medicaid enrollment in states participating in expansion under the Affordable Care Act, “can enable more of them to avoid returning to jail or prison by connecting them to needed mental health, substance abuse, or other treatment.  This is why many state corrections agencies and county governments are collaborating with state Medicaid agencies on projects designed to enroll low-income people being released from jails or prisons.”

On average, approximately 75% of the US prison population consists of nonviolent offenders, many of whom have a myriad of mental and behavioral health challenges and/or are fighting addiction. According to Solomon, “alcohol plays a role in over half of all incarcerations, and illicit drugs are involved in over 75 percent of jail stays.” But only 11 percent of inmates receive any type of treatment, while comorbid conditions are prevalent.

I haven’t taken the time to explore the cites and research that Solomon provides, so I want to be careful not to be advocating for something that obviously needs to be carefully considered, debated and vetted. My point is simply this: we should be investing more to determine – and evidence – whether and how this type of policy intervention can help achieve a stronger, more accessible, more effective mental health system.

We need to change our perspective on mental health. Fighting stigmatism – yes, important. I get that. But I believe we should be investing more heavily to educate the country about how intervention and treatment works – and how it can lower costs to families, communities and the country in the long run. There is a much better chance of redirecting funding from other sources than securing funding for new initiatives. That’s the political reality – like it or not.

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Medicaid · Tagged: , , , , , , ,
Jun 26, 2014

Don’t Make Mental Health Policy About the Stigma

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Cost of not caring: Stigma set in stone by Liz Szabo, USA TODAY.

This second article of a USA Today series, Mentally Ill Suffer in Sick System, this morning began exploring, "the human and financial costs that the country pays for not caring more about the nearly 10 million Americans with serious mental illness." But the article didn’t address any of the aggregate human costs nor any of the financial costs the country pays due to serious mental illness. Maybe future articles will, and that’s what I would like to encourage with this post.

Now, admittedly, USA Today isn’t in the top 10% of resources I normally rely upon for keen insights and emerging trends and drivers in healthcare, but nonetheless I think they deserve enormous credit for using their national reach to bring greater awareness to a critically important issue.

From a public policy perspective, however, this first contribution is wide of the mark in advancing the type of dialogue that could actually lead to meaningful public policy initiatives impacting mental and behavioral health services. So though I very much doubt their editors will ever see this post, I would like to provide some input that might be useful in developing content for future articles in the series.

Today’s article focused on two themes: the latent impact that stereotypes associated with mental illness still have, often creating self-absorbed obstacles to seeking and receiving much-needed diagnosis, treatment, support services and ongoing care; and the dramatic lack of sufficient resources committed to helping those who are brave enough to seek assistance and support.

Of course, stigmatism is still very real, yet very difficult to understand: it isn’t just a case of stereotyping and ignorance. Mental illness is difficult for many of us to comprehend because the mechanism responsible for its existence is the same mechanism we use to understand it. Most of us can use our brains to understand heart disease, diabetes and lung cancer. But somehow using our brains to explore and reason through a disease process that in others (or, to be sure, often ourselves) impacts our thinking can be uncomfortably counterintuitive.

The inherent stigmatization isn’t just in the fact that someone with mental illness is, "different." It’s the added frustration of having difficulty understanding why they are different. An individual receiving chemotherapy for cancer may look different than their appearance prior to disease. Someone who has had an amputation resulting from diabetes has a noticeable difference in appearance. But mental illness very often doesn’t carry with it the externalities of these changes in appearance (the manifestation of behavioral health consequences resulting from mental illness may lead to dramatic changes in appearance, but those are usually self-chosen much the same way one would choose a different hair color or style).

So while it may be said that ignorance is a lack of understanding acted upon, I agree we should continue to concentrate efforts on building understanding and awareness through continued education, rather than trying to coach away ignorance through reprimand and humiliation that too often characterize so many public awareness campaigns.

Such efforts have had beneficial impact: as a society we are generally much more accepting today than 20 years ago that mental illness is not a self-chosen condition bearing the shame of poor choices and moral subservience. And they have concurrently raised awareness about the urgent need to develop more effective public policy to address accelerating mental and behavioral health needs.

And so, as related in the USA Today article, the most emotionally convenient and expedient approach to lobbying for additional funding in support of MH/BHS is to continue making the case that mental illness should be viewed just as any other disease of a human organ – since the brain is, after all, a human organ. This reflects the inherent strategy that fighting the stigmatization of mental illness will hold sway over those able to increase funding of MH/BHS policy initiatives. But I don’t think it will because every dollar allocated to healthcare is becoming increasingly precious.

From a policy perspective, I believe it is both folly and a wasted effort to spend valuable resources on lobbying for more funding without being able to provide realistic and achievable budgetary offsets. To do this, advocates of MH/BHS programs need to focus their time and energy on generating evidentiary support for where and how funding of existing programs that address the consequences of mental illness can be more effectively invested in programs that diagnose and treat mental illness – i.e., before that illness results in consequences which place resource strain on other areas of social health and welfare (e.g., utilization of hospital emergency departments and the criminal justice system, the economic impact on families and the cascading effect that has on the rest of society). This is, I assume, what USA Today claims the series intends to do via relaying the “human and financial costs” of mental illness. We will see.

In healthcare, we are now living in an era where the expectation that research and evidence support clinical decision-making has steadfastly made its way into organizational administrative and financial decision-making. Quite obviously, we cannot hope that will ever be the same in Congress, but through the Affordable Care Act and various programmatic changes impacting state Medicaid budgets legislators are by default forcing healthcare providers to much more carefully analyze alternative investments – and to use return on investment as a tool for that analysis. Mental health advocates need to recognize this reality if they want their efforts to ultimately result in constructive public policy consistent with their overarching goals and objectives.

I really hope this understanding is reflected in future articles in the USA Today series. I understand anecdotal human-interest stories that tug at the heartstrings help sell newspapers, but they contribute very little to the knowledgebase of understanding needed to assess where and how limited resources can best be reallocated to address this tremendously difficult challenge that we all face as a society.

Cheers,
  Sparky

Picture Credit ~ Jim C. Jeong for USA Today

Filed Under: Editorials & Opinions, Mental/Behavioral Health · Tagged: , , , , ,
Jun 15, 2014

Much Ado About Value

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I was recently honored when Greg Scandlen took time to consider and write about some of the work I shared with him that has been produced by Michael Porter on value-based healthcare delivery. Mr. Scandlen is a regular contributor for the National Center for Policy Analysis’s Health Policy Blog, and in his article,  Value Based Payments, he argues that attempting to use the concept of value to drive systemic improvements in the US healthcare delivery system is misguided because of the inherently subjective and multidimensional nature of patient outcomes (Porter has used the equation of Value = Outcomes/Cost as the basis of arguing for industry transformation).

Michael Porter, “is generally recognized as the father of the modern strategy field, and has been identified in rankings and surveys as the world’s most influential thinker on management and competitiveness.” He has extensively researched and written on healthcare, establishing a comprehensive body of work that supports the need for reorganization of our healthcare system framed around value-based delivery.

After collaborating with Elizabeth Teisberg on their seminal work, Redefining Healthcare, in 2006 Porter wrote an article in 2010 for the New England Journal of Medicine: What is Value in Health Care? This is the article Mr. Scandlen references in his article. There are several additional contributions from Porter that add meaning and understanding to the value paradigm discussion, and these include:

Measuring Health Outcomes: The Outcome Hierarchy, a supplementary appendix to the above-referenced NEJM article;
How to Solve the Cost Crisis in Health Care (with Robert Kaplan) in the September 2011 edition of Harvard Business Review; and
The Strategy That Will Fix Health Care (with Thomas Lee) in the October 2013 edition of Harvard Business Review

There are a couple of areas where my perception of value as a catalyst for delivery transformation differs from Scandlen’s.

First, while I agree it’s true individual value is a subjective reality, my understanding of Porter’s work does not advocate for creating objective measures of value on behalf of the patient. In the October 2013 article referenced above Porter writes, “in healthcare, the overarching goal for providers, as well as for every other stakeholder, must be improving value for patients, where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.”

Second, Scandlen takes issue with Porter’s claim that, “in any field, improving performance and accountability depends on having a shared goal that unites the interests and activities of all stakeholders,” arguing that is counterintuitive to how competitive markets function – which Porter himself advocates for and has written about extensively. But I think Scandlen has too narrowly applied this axiom. Using his own example of how difficult it would be to imagine IBM, Apple and Microsoft having a shared goal, I would argue the goal they shared was to develop and provide lower-cost personal computing capacity and technology to individual consumers.

This wasn’t a coordinated or collusive effort to limit competition or share profits – it was a market-driven opportunity that each corporation recognized independently to bring value to consumers and be rewarded accordingly. Porter recognizes that in healthcare, in order for providers and organizations to transform delivery models based on value they must all recognize – and act upon –  the perceived economic benefits of creating value for the patient.

The graphic accompanying this post provides the six steps outlined in the October 2013 HBR article that Porter argues healthcare organizational leadership, patients and health plans/employers must pursue to achieve a high-value care delivery system. The key concepts embodied include integrated care delivery, transparency, outcome-measurement, accountability and geographic expansion of specialized capabilities (e.g., what the Cleveland Clinic has been doing through affiliations such as their recent minority interest in Akron General Hospital).

Finally, I do not believe measuring outcomes (the ubiquitous challenge facing Porter’s value equation) is a long-term effort in futility. Porter’s outcome hierarchy was an attempt to recognize and address the multidimensional nature of outcomes that Scandlen identifies. Many other such similar efforts are ongoing across the world. With the continual advancement of Big Data, the ability to monitor, analyze and report on patient-related data and information across the full spectrum of an outcome will continue to become more and more useful: to providers, insurers – and most importantly, patients.

Where the concept of outcome measurement runs into its biggest theoretical challenge is when payment models such as ACOs and episodic payment bundling seek to use such data to objectify achievement of patient value as a measurable statistic (i.e, benchmarking) used as an incentive to influence provider behavior. But the old adage of not being able to manage what you cannot measure is a critical element of value-driven performance improvement that I believe Porter effectively argues is at the heart of transforming our delivery system.

Value-driven payment models are in their genesis. Any type of industry transformation at this juncture is going to endure understandable resistance and criticism.  The train has left the station. Industry transformation based upon value-driven performance is already well entrenched as represented by organizations such as St. Joseph Mercy Oakland Hospital (Pontiac, MI), Adirondack Medical Home Pilot (NY) and Dignity Health, Hill Physicians and CalPERS.

There is legitimate concern that data and analysis on outcomes will be used to supplant patient choice. I don’t believe that is what Porter and colleagues had in mind when writing about value-driven healthcare delivery. Of course that doesn’t mean their intentions won’t be bastardized in the interest of bureaucratic ignorance and expediency. This risk must be carefully guarded against, but it does not in and of itself change the important role value must play in transforming our healthcare delivery system.

Cheers,
  Sparky

Filed Under: Editorials & Opinions · Tagged: , , , , ,
May 29, 2014

The Human Spirit as an Organ

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Brain-Lightbulb1-214x300May 23rd, 2014 – Santa Barbara, California: another day, another shooting rampage, a few more souls lost to mental illness. More calls for gun control. More calls for funding of public health programs. More wringing of our hands and gnashing of our teeth where as a society we wrestle with what we can do to prevent disturbed individuals like Elliot Rodger from senselessly taking the lives of others.

I’d like to take a pragmatic approach to what we might do, starting with gun control.

As we saw recently, opponents of gun control are very effective politically at making impassioned arguments that owning a gun is the manifestation of a God-given right to defend personal self and property against threats from others – and most particularly in the minds of some political activists  (i.e., the Tea Party), the government. And they have huge lobbying strength.

Now I feel I have to share, that even for those most zealous gun enthusiasts with huge caches of automatic weapons I truly don’t understand how they would expect to defend their neighborhood against an AH-64 Apache helicopter should there ever be a military-supported government coup. Can’t you see it? A long row of sixty-something Harley riders with ammo strips strapped over their shoulders, long grey hair flowing from under their skull n bones bandanas. Waving their AK-40’s wildly as they fall like dominoes. Sort of like us fifty-something’s having to get under our desks in grade school during the 60s to rehearse protecting ourselves against a nuclear attack. But I digress.

Humor aside,  I think it’s important in this discussion to understand that gun ownership is a culturally ingrained part of wide swaths of our society. Unless that changes gun control legislation and regulations will have about as much success in the 21st century that Prohibition had against controlling alcohol production and consumption in the early 20th century. And perhaps there is a measure of truth in recognizing that in both instances the policy focus is misplaced by not recognizing the ultimate responsibility of acts committed under the influence or with a weapon (or both) lies with the individual, not the bottle or the gun.

So ruling out much hope for gun control as a viable approach to prevent these types of tragedies we next turn to doubling down on promoting policies that will expand access to mental health services.  But what if rather than spending more money to treat mental illness and its symptoms as distinct and separate from physiological well being we instead doubled down on efforts to understand how critically important it is to treat mind and body together.

I realize there are earnest efforts all across the country to integrate physical and mental health and move toward holistic well being. But from what I have seen those efforts are mostly incremental in nature and not going to create the transformational shift in health practitioners’ approach that can ultimately have the type of impact on mental illness we seek.

I think what is required is a paradigm shift in thinking about where and how mental health integrates with the overall health and wellness of the individual. We need to begin recognizing that mental well-being is a spiritual reality that, while ultimately the manifestation of physiological attributes, exists independent of those attributes.

And in this way it is just as much a vital organ as is the heart, the brain and so on. And that leads me to believe we should be thinking of human mentality as an organ. Just as our physical organs are necessary to provide human cells with basic needs to sustain life, we are learning more every day how important our human mentality is to cellular health.

I believe if we can broadly achieve this vantage it would change the way we approach research, the way health practitioners integrate awareness of mental health into diagnoses and treatments, the way we approach and treat symptoms of mental illness – and it would change the way we view mental health policy.

Your thoughts?

Cheers,
  Sparky

Filed Under: Editorials & Opinions, Mental Health · Tagged: , , , ,
May 14, 2014

Why Can’t Healthcare Innovate?

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Whether viewed as paradox or conundrum, the healthcare industry’s relative inability to innovate has long been a source of both fascination and frustration. In the May 8, 2014 edition of the New England Journal of Medicine,  David A. Asch, M.D., M.B.A., Christian Terwiesch, Ph.D., Kevin B. Mahoney, B.A., and Roy Rosin, M.B.A. write about this phenomenon in Insourcing Healthcare Innovation.

Describing the understandable resistance of healthcare professionals to embrace problem-solving techniques from unrelated industries because the complexity of healthcare delivery is most often not well understood, those professionals are by definition usually most interested in exploring new ideas, new approaches and the pursuit of new knowledge. This apparent irony, the authors believe, might be effectively synchronized if a different approach could be taken to reconciling innovation with contextual understanding.

The approach they share is a four-stage design process they believe can achieve this reconciliation. The four stages include: contextual inquiry (understanding the processes currently in place); problem definition (ensuring the right problem has been understood and defined); divergence (exploring alternative approaches) and rapid validation (ability to move from theory to implementation).

If these sound familiar, it is because the general direction of proceeding from understanding where you are to achieving where you would like to be in an orderly fashion is the foundation of many approaches to strategic planning. So from that vantage there isn’t anything particularly revolutionary about the process described.

But understanding the core resistance to such processes – that the way in which healthcare practitioners are educated, trained and practice is frequently counterintuitive to innovation techniques successfully utilized in other industries – is an important distinction. What this translates into is making the requisite investment to understand the unique attributes and complexity of healthcare delivery – its distinctive product offerings, its highly dependent reliance upon personal relationships, its unbelievably complicated regulatory environment – as a necessary component of any planning effort.

It takes time and effort to build the needed understanding of the unique challenges that healthcare practitioners face. You have to ask probing questions and not hesitate to admit your lack of understanding: a fair balance of humility and curiosity can go a long way to building key relationships and creating the requisite knowledgebase necessary to innovate.

In other words, individual egos often create barriers to innovation processes that are attempted to be imported from other industries. More so than representing a different way of approaching innovation in healthcare, what this article does is reinforce a tried and true means of any planning effort: listen and learn before you lead.

Cheers,
  Sparky

 

Filed Under: Innovation · Tagged: , , , ,
Apr 29, 2014

“A Very, Very Slippery Slope”

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The New York Times is reporting this afternoon that Donald Sterling, owner of the Los Angeles Clippers, has been barred from the NBA for life and fined $2.5 million in lieu of the secret taping of what he thought was a private conversation during which he expressed remarks that were both ignorant and extremely offensive.

The NBA understandably wants to protect its brand. And if in its collective discretion it believes that Mr. Sterling’s remarks damage that brand, everyone else who has a vested financial interest in the brand has the right to entirely and completely disassociate from Sterling in any legally manner permissible. I totally get that.  It’s the means to the end that I find disturbing in this situation.

According to a statement issued by NBA Commissioner Adam Silver under the NBA Constitution – whatever that is – it is apparently permissible to ban someone from attending future NBA games (and practices). I would like to understand how that squares with the other Constitution that I assume is still considered higher authority.

And speaking of that Constitution, there is the very first amendment, which as part of the Bill or Rights guarantees citizens living under it the right of free speech. What this incident will – or at least should – do is start a robust debate in this country about where publicly contrived penalties and sanctions stemming from offensive and/or hurtful speech cross the line into becoming de facto limiting of free speech.

Free Speech Means Tolerating Ignorance & Persecution

Now, nobody has told Mr. Sterling that he has to stop talking. But I question whether the penalties levied by the NBA border on the incredulous. They serve notice that offensive speech (even when said in private) is not only intolerable – but will be penalized in such a fashion as to act as a restriction of that speech. And there is also the issue of whether Sterling’s fifth amendment right to due process has been violated by being forced into forfeiting his personal ownership of the Clippers.

I’m sure someone like Sterling has many legal eagles at his disposal, and he doesn’t need me playing the role of constitutional counsel. And frankly, it makes me uncomfortable thinking that someone may interpret this post as being in any way supportive of Sterling’s remarks. I am not. But I am being supportive of his right to say whatever he wants within the historic understanding of what constitutes free speech.

We are losing that historical perspective. Free speech in this country is, always has been – and hopefully always will be – a double-edged sword. The video clip I inserted above does a fine job of expressing that. And if that doesn’t do it, then I think what Mark Cuban, owner of the Dallas Mavericks said hits the nail on the head:

“What Donald said was wrong. It was abhorrent. There’s no place for racism in the N.B.A., any business I’m associated with, and I don’t want to be associated with people who have that position. But at the same time that’s a decision I make. I think you’ve got to be very, very careful when you start making blanket statements about what people say and think, as opposed to what they do. It’s a very, very slippery slope.”

A slippery slope indeed. The media (as in what used to be the press) has historically been thought of as the fourth branch of government because one of its fundamental roles was to investigate and report factual evidence that stood apart from political discourse. We know that reality has been obfuscated nearly beyond recognition today, and we have sat back and enjoyed being entertained while it happened.

Those who have read my blog should know where I generally stand politically. So if this event alarms me, maybe it should you too. Maybe not – I’d love to hear your thoughts. I think it’s time we start rethinking what we’ve allowed to happen in this country before you or I are the next people whose liberties are threatened because we say the wrong thing.

Cheers,
  Sparky

Filed Under: Editorials & Opinions · Tagged: , , , ,
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